SYNOPSIS

The essential feature of panic disorder is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable. As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization). There is often also a secondary fear of dying, losing control, or going mad. Panic disorder should not be given as the main diagnosis if the patient has a depressive disorder at the time the attacks start; in these circumstances the panic attacks are probably secondary to depression.

An individual diagnosed with panic disorder needs to meet all of the following criteria:

Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: (Note: The abrupt surge can occur from a calm state or an anxious state.)

Palpitations, pounding heart, or accelerated heart rate.

Sweating.

Trembling or shaking.

Sensations of shortness of breath or smothering.

Feelings of choking.

Chest pain or discomfort.

Nausea or abdominal distress.

Feeling dizzy, unsteady, light-headed, or faint.

Chills or heat sensations.

Paresthesias (numbness or tingling sensations).

Derealization (feelings of unreality) or depersonalization (being detached from oneself).

Fear of losing control or "going crazy".

Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy").

A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situatioins, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumati stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Effective Therapies

Cognitive behavioral therapy (CBT), benzodiazepines and antidepressants (SSRI + SNRI) are very effective as treatments for this disorder.

Ineffective therapies

Vitamins and dietary supplements are ineffective for this disorder.

Complications

Individuals with Panic Disorder often anticipate a catastrophic outcome from a mild physical symptom or medication side effect. Such individuals are also much less tolerant of medication side effects and generally need continued reassurance in order to take medication. The belief that they have an undetected life-threatening illness may lead to both chronic debilitating anxiety and excessive visits to health care facilities. Demoralization is a common consequence, with many individuals becoming discouraged, ashamed, and unhappy about the difficulties of carrying out their normal routines. These individuals may frequently be absent from work or school for doctor and emergency-room visits, which can lead to unemployment or dropping out of school.

Psychological Comorbidity

From 10% to 65% of individuals with panic disorder also have major depressive disorder. Often individuals may treat their panic disorder with alcohol or medications, and thus may develop alcoholism or drug addiction as a consequence. Social anxiety disorder (social phobia) and generalized anxiety disorder have been reported in 15%-30% of individuals with panic disorder, specific phobia in 2%-20%, obsessive-compulsive disorder in up to 10%, and posttraumatic stress disorder in 2%-10%. Separation anxiety disorder in childhood has been associated with this disorder. Hypochondriasis commonly occurs in panic disorder.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder. Some individuals with panic disorder show signs of compensated respiratory alkalosis. Sodium lactate infusion or carbon dioxide inhalation will more commonly trigger panic attacks in individuals with panic disorder than in control subjects or individuals with generalized anxiety disorder.

Prevalence

The lifetime prevalence rate for this disorder in the general population is 1% to 2%. The 1-year prevalence rate is 0.5% to 1.5%. Panic disorder is diagnosed in approximately 10% of individuals referred for mental health consultation, and in approximately 60% of individuals in cardiology clinics. Approximately one-third to one-half of individuals diagnosed with panic disorder in community samples also have agoraphobia (i.e., fear leaving home alone). Women are 2 to 3 times more likely to develop panic disorder than men.

Course

This disorder may begin at any age, but most individuals develop this disorder between adolescence and the mid-30s. A small number of cases begin in childhood, and onset after age 45 is unusual (but can occur). The usual course is chronic. Some individuals have a chronic, episodic course (with episodic outbreaks with years of remission in between). Others have continuous severe symptomatology. Although agoraphobia may develop at any point, its onset is usually within the first year of panic disorder.

Outcome

The agoraphobia accompanying panic disorder may become chronic regardless of the continued presence or absence of panic attacks. Anxiety Disorder Clinics report that, at 6-10 years posttreatment, about 30% of their patients are well, 40%-50% are improved but symptomatic, and the remaining 20%-30% have symptoms that are the same or worse.

Familial Pattern

Twin studies indicate a genetic contribution to the development of panic disorder. If the age at onset of the panic disorder is before 20, first-degree relatives have been found to be up to 20 times more likely to have Panic Disorder. However, as many as one-half to three-quarters of individuals with Panic Disorder do not have an affected first-degree biological relative.